Va Greater Los Angeles Healthcare System

The American Legion SYSTEM WORTH SAVING

VA GREATER LOS ANGELES HEALTHCARE SYSTEM | LOS ANGELES, CA Date: January 23-25, 2017 Veterans Affairs & Rehabilitation (VA&R) Commission Member: Howard Darter Deputy Director of Veteran Affairs and Rehabilitation (VA&R) Division:Roscoe Butler Deputy Director Employment and Education Division: Mark Walker

Overview people attended the meeting. Many veterans praised the VAG- LAHS for the care and services provided. Executive Leadership Briefing On January 24th and25th, 2017, Veterans Affairs and Rehabili- tation Commission Member Howard L. Darter, Deputy Direc- tor of Health Care Roscoe Butler, Deputy Director for Employ- ment and Education Mark Walker and The American Legion Department of California staff met with the Executive Leader- ship team and various department heads to discuss best practices and challenges. The position of Associate Director is currently vacant. When asked, what is the medical center’s biggest challenge, the Assistant Director said, “Running the VAGLAHS is like running a city with eleven sites of care.”The VAGLAHS is spread across 388 acres and treats over 95,000 veterans. The Director spoke briefly about the VAGLAHS’s Master plan The VA Greater Los Angeles Healthcare System (VAGLAHS) is which calls for 1,200 Permanent Supportive Housing Units, 840 one of the largest health caresystems within the Department of supportive housing units, a resource center for veterans and Veterans Affairs.It is one component of the VA Desert Pacific their families, and a proposal to increase access to transporta- Healthcare Network (VISN22) offering services to veterans re- tion.While various leases will produce additional funding, Ann siding in Southern California and Southern Nevada.VAGLAHS Brown, Director of the VAGLAHS explained, the funds will not consists of two ambulatory care centers, a tertiary care facility be enough to support the program and the medical center’s un- and 10 community-based outpatient clinics (CBOCs).The VA- funded mandates. GLAHS serves veterans residing throughout five counties: Los The Executive Leadership team reported staffing challenges for Angeles, Ventura, Kern, Santa Barbara, and San Luis Obispo. providers is difficult to recruit specialties and areas where pri- There are 1.4 million veterans in the VAGLAHS catchment vate sector salaries are competitive.Additionally, it is difficult to area.The VAGLAHS is affiliated with both the UCLA School of recruit at several of the CBOCs in rural areas.There are also sal- Medicine and the USC School of Medicine, as well as more than ary discrepancies with the private sector for physician extend- 45 colleges, universities and vocational schools in 17 different ers including Physician Assistants (PA) and Nurse Practitioners medical, nursing, paramedical, and administrative programs. (NP). Town Hall Meeting The VAGLAHS is currently working on developing a facility On January 23, 2017, a town hall meeting was held at American level strategic plan. In the interim, the facility has been working Legion Post 43, 2035 N. Highland Ave, Los Angeles. The meet- with VA leadership, local community partners and community ing consisted of a small group of local veterans, representatives leaders to develop and implement a facility Draft Master Plan, from local congressional offices, VA’s executive leadership, and which is a blueprint for the development of VA’s West Los An- legion members from the Department of California. geles north campus. The north campus will help create a vibrant community where veterans can receive housing, healthcare, In keeping with previous town hall meetings, the American Le- benefits, and other supportive services – with a specific focus gion held an open forum that allowed everyone an opportunity on chronically homeless veterans and other underserved vet- to voice their concerns, issues, and comments regarding the eran populations. This is in addition to the future development medical care and services provided by the VAGLAHS. Twenty of their south campus also designed to create a state-of-the-art

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hospital with and clinics that will serve as the main focus of beds for all specialties of which 1,049 are operational. The VA- their local strategic plan over the next 5-10 years. GLAHS had 7,493 admissions and 1,396,297 outpatient visits Wait List in FY 2016. Accreditations Average wait time for Primary Care, Speciality Care, Mental Health Care was reported as follows: • Last Joint Commission - August 15- 19, 2016 The VAGLAHS reported the average wait time for homemaker- »» Hospital Accreditation: As a result of the accreditation Primary Care Specialty Care Mental Health activity conducted on the above date(s), requirements for improvement were identified in the report. You will have 7.4 as of 14.68 days as of 6.5 days as of follow-up in the area(s) indicated below: 12/15/2016 12/15/2016 12/15/2016 • Evidence of Standards Compliance (ESC) home heath aid services varied because the program is at full capacity.Patients suffering from spinal cord injuries, or unique a. Nursing Care Center Accreditation: As a result of challenges are given priority and receive care within one week the accreditation activity conducted on the above or admitted to hospice care. date(s), Requirements for Improvement have been identified in your report. You will have follow-up in Meeting with the VAGLAHS Staff the area(s) indicated below: Immediately following the meeting with the VAGLAHS Execu- b. Behavioral Health Care Accreditation: As a result tive team, VA&R Commission members Darter, Roscoe Butler, of the accreditation activity conducted on the above and staff from The American Legion Department of California date(s), Requirements for Improvement have been met with the VAGLAHS staff over the next two days to obtain identified in your report. You will have follow-up in insight about the VAGLAHS’s best practices and challenges.The the area(s) indicated below: majority of the staff identified recruiting as the medical center’s c. Home Care Accreditation: As a result of the accred- number one challenge. itation activity conducted on the above date(s), there During the meeting with Human Resources (HR), the System were no Requirements for Improvement identified. Worth Saving (SWS) team learned that HR is currently con- • Last Accreditation of Rehabilitation Facilities (CARF): June ducting a business planning process.The HR department has 27-28, 2016 28 vacancies including the Chief and Assistant Chief of Human Resources positions. The medical center has approximately 408 Three-Year Accreditation Expiration: June 30, 2019 vacancies.However, HR indicated that due to poor data input, The SWS team led an exit briefing with the VAGLAHS Execu- staff are in the process of validating this information. tive leadership to brief them on our findings and recommenda- In the SWS team discussion with the Financial Management tions.The number one challenge faced by the VAGLAHS medi- Officer (FMO), the FMO identified the inability to move funds cal center is working down the large number of vacancies.We from one account to another and salaries as his top two chal- apprised management about comments from staff about how lenges.He reported for FY17; the medical center received to date pleased they were with the stable leadership and the Executive $699,023,7271. Leadership team being put in place at the medical center. The VAGLAHS projected a veteran population of 368,590 in Homeless Shelter Visit Medical Center 2017 Budget On Wednesday, January 25th, the System Worth Saving Team General Post $ 70,536,273 met with the VAGLAHS Homeless Veterans Program person- nel to discuss their programs and services that assist homeless Medical Services $ 555,817,315 veterans and their families. The goal of the program is to pro- Facilities $ 72,670,139 vide at-risk and homeless veterans with access to stable housing; establish a means of financial support; strengthen attachments Total $ 699,023,727 to their community; and establish medical, mental health and additional services. VA staff discussed their processes of out- Fiscal Year (FY) 2017. Of this number, 138,281 are enrolled in reach, intake and placing at-risk and/or homeless veterans in the VAGLHCS. The VAGLAHS is authorized 1,087 inpatient the proper program/service. Los Angeles has critical issues of sheer numbers of homeless veterans, the size of the city - to in- 1 Amount received on station as of the date of site visit

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clude traffic and transportation issues - as well as a premium on and Salt Lake City, combined. Los Angeles has cut unsheltered affordable housing. These issues can create numerous obstacles homelessness by 43 percent and veteran homelessness overall when it comes to assisting homeless veterans with their various by 41 percent in one year. These numbers represent a tremen- needs in reintegrating back into independent living. dous effort by the VA, City of Los Angeles, Community Service Also addition, our team went on a tour of the New Direction Providers, Veterans Service Organizations and other commu- for Veterans (NDVets), which is located in Building 257 (within nity partners. the Veterans Welcome Center) on the VA West LA campus. The Best Practices Veterans Welcome Center is a unique and innovative program, the only one of its kind at a VA facility in the nation, and repre- Nursing sents a collaborative approach to working with veterans follow- • Community Living Center (CLC) Nurse Managers’ Boot- ing a “housing first” philosophy. More than 150 veterans use the camp.The nurse managers in CLC had been in their positions Veterans Welcome Center each day. NDVets services include for one year or less.The boot camp was created to provide assistance with planning and searching for housing, obtaining them with knowledge and resources that would help them documentation, accompanying and transporting veterans to ap- succeed.The boot camp was successful and led to the creation pointments, advocating with landlords, covering move-in costs of a VISN-wide Nurse Manager Academy. and utilities, and referring veterans to services. Also, NDVets has a 35-bed Bridge Housing Program that offers immediate • CLC “Honoring Our Heroes” Resident Showcase Presenta- shelter and meals for veterans who are awaiting placement in tion – where we have a staff member present a resident who permanent supportive housing, as well as access to healthcare has volunteered to share their life story to other staff members and transitional services as needed. Lastly, it’s also important to and residents. This allows everyone involved to remember the note that VA is developing housing for homeless veterans. As “human” connection and the person behind “a patient.” part of the 2015 legal settlement, the agency agreed in principle • Call light system at the CLC.Call lights are no longer being to turn the West LA VA Campus (on the west side - largest un- answered at the desk, but now the staffs come to the bedside developed property) into a residential village for 1,200 veterans. directly. The VAGLAHS community partners and other stakeholders • Weekly meetings the CLC has with nursing risk management have been intensely active in combating veteran homelessness. and the nurse managers with the residents of the CLC.This Furthermore, the VA is continuing to work to eliminate veteran was organized by ADPCS which is a best practice ensuring homelessness by educating and empowering veterans and their that each resident is heard and their concerns are addressed. families through proactive outreach and effective programs/ • RN New Grad Transition to Practice Program (TTP) includ- services. However, there remains much work to be done in Los ing the “Veteran Connection” piece where we collaborate with Angeles. the Volunteer Services and have each new grad RN partici- Lastly, one of the goals of The American Legion is to help bring pate at a Veteran outreach event to engrain early on in their federal agencies, nonprofit organizations, faith-based institu- nursing career, that VA nursing is a special kind of nursing. tions and other stakeholders to the table to discuss best practic- • Just Culture implementation es, along with funding opportunities, so homeless veterans and their families can obtain the necessary care and help in order • AcuStaf - Is an off the shelf labor management software pack- for them to properly transition from the streets and shelters into age that is used by nursing Service to improve efficiency and gainful employment and/or independent living. labor management operation Statistics For Veteran Homelessness In Los An- • NP Transition Program – in order to provide support and help geles ensure success of new NPs graduating through our scholar- ship program (NNEI), we are offering a transition program In Los Angeles, veterans comprise a little over 3 percent of the to allow a smooth transition from the RN role to the NP role. general population but makeup about 11 percent of the home- • Utilization of the Bed Management Solution (BMS) for hos- less population. Based upon the 2016 Point-in-Time count, pital throughput. there are approximately 9,600 homeless veterans in the State of California. Los Angeles City (and County) has roughly 2700 • Hiring fair of those homeless veterans. Since January 2014, Los Angeles • Evidence Based Practice Fellowship – nurses and allied health has housed over 8,000 homeless veterans - that is more veter- staff participate in a fellowship to create a project to improve ans housed than the cities of Houston, New Orleans, Phoenix,

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patient care based on the evidence. This project has won spectrum of patients who have trouble driving to get their ONS and other awards. It is unique because we focus on staff subspecialty diabetes care. nurses and allied health staff who do not have doctoral level education. Gastroenterology and Hepatology • Improving Quality of Health Care by Nurse Practitioners. • Colorectal Cancer Screening- Automated reminders for sur- Measuring a Veteran’s Quality of Healthcare Managed by a veillance of polyps and for early cancers have endoscopic ap- Nurse Practitioner in a Veterans Affairs using Professional proaches to treatment using Endoscopic Mucosal Dissection. Practice Evaluation and Core Performance Measures. • Starting a trial funded by the National Cancer Institute for early detection of pancreatic cancer. Primary Care • New treatments for hepatitis C which result in an almost • Primary Care Mental Health Integration – Mental health 100% cure rate. team is embedded into primary care clinic • Since fatty liver and obesity are increasing in prevalence, • Primary Care Health Coach Classes started a clinical trial using Obetichoic Acid that is IRB ap- »» Biofeedback for medical conditions proved to study its utility and safety to treat fatty liver and »» Mindfulness for Pain Management prevent progression to cirrhosis. »» Get back to Sleep: Insomnia Class • Have an outstanding informatics platform to track patients with liver fibrosis and cirrhosis using a non-invasive test »» Healthy Living called Fibroscan to identify higher risk Veterans and thereby • Primary Care PACT Titration Pharmacists – work with pa- prevent liver cancer. tients and PACT Team to improve diabetic control • Developed a Doppler Probe to identify high risk vessels to • Primary Care Shared Medical Appointments – multidisci- effect treatment in patients presenting with non-variceal GI plinary team works with a group of Veterans to help improve bleeding. diabetic control and blood pressure control. Patient Centered Care • Direct Scheduling by PACT MSA’s for: • Welcoming new employees with a half day Patient Centered »» Audiology Care retreat. »» Optometry • Engaging Veterans with Whole Health/Integrative Health »» Echocardiogram practices/pathways including 5 week Intro to Relaxation for Self-Care Series, Meditative Movement, I rest Yoga, Healing »» Imaging – Ultrasound Touch, Guided Imagery, and Aromatherapy. Endocrinology • Tai Chi and Yoga classes. • For diabetics, aim for annual retinal screening, flu shots, and • Training nursing Holistic Nursing techniques to offer inpa- routine follow up of A1C and urinary protein to ensure the tient and outpatient for decreased pain and overall wellbeing. best outcome.These are all HEDIS measures.Additionally, • Also, partnering with Integrative Medicine and Mental review VA database to seek out patients with poor glycemic Health, HPDP and Health Coaches to provide interdisciplin- control to try to help them. ary clinics such as Healing Touch during Ear Acupuncture, • Working with Women’s Health, Psychology, Pharmacy and and Whole Health Orientation clinics. Social Work to establish a multidisciplinary transgender pro- • Partnering with Nursing offering Interactive Patient Care via gram Get Well Network, including health education/wellness vid- • Put together insulin algorithms for use on the inpatient ser- eos on inpatient unit. vice. • Providing Employee Wellness for staff via 2 employee gyms • Started a clinic dedicated to seeing follow up patients who and Wellness is Now Program, along with health/wellness present to the Emergency Room with poorly controlled dia- lunch and learn sessions. betes • Have augmented telediabetes clinic to give care to a broader

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Mental Health »» Same-day mental/behavioral health appointments as part • WLA VA offers a 10-week Comprehensive Pain Rehabilitation of veteran primary care services in accordance with the lat- Program. The mission is to provide evidence based treatment est research of veteran preferences and treatment recom- for chronic pain from an interdisciplinary perspective with mendations Psychology, Physical Therapy, Occupational Therapy, Pain »» Biofeedback services for problems such as pain manage- Medicine and integrative and other modalities. Patients have ment, and anxiety as well as other common veteran strug- improved mood, functioning, and quality of life following par- gles ticipation. The program is CARF (Commission for Accredita- »» Mindfulness skills training including Mindfulness-Based tion of Rehabilitation Facilities) accredited. Stress Reduction, an effective approach to reducing a vari- • Evidence-based Cognitive Behavioral Therapy for Chronic ety of problems and improving quality of life Pain that reduces pain, anxiety, depression and disability »» Cognitive-Behavioral Therapy for primary care patients • •Evidence-based substance use disorder treatment that uses »» Acceptance and Commitment Therapy for primary care Cognitive Behavioral Therapy (CBT), Mindfulness, Motiva- patients tional Interviewing and Contingency Management »» Primary care psychiatry services • Our Mindfulness Programs particularly Mindfulness Based Stress Reduction (MBSR) and Mindful Self-Compassion • GLA offers the only Clinical Forensic Team in the country. (MSC) recently were awarded a Best Practice Everywhere by »» The Clinical Forensic Team works with Veterans released Dr. Shulkin for 2016. from long-term institutionalization in prison and/or state • •MBSR provides Veterans with the Integrative Health path- forensic hospital (Atascadero State Hospital) that conse- ways to health and wellness increasingly in demand from our quently are at high risk for poor community re-integration. Veteran consumers and difficult to access in the private sec- »» The Clinical Forensic Team serves as a bridge between tor. Veterans are asking for Whole Person Health approaches prison/mental hospital and VA, through pre-release clini- for both physical and mental health concerns that move away cal contact with the Veteran and development of a GLA from a “pill for the ill” model of care and empowers Veter- on-site housing/treatment plan. ans to engage with their care and manage stress and chronic »» The Team’s involvement is typically short-term (three to six health conditions in their lives. MBSR is an 8-week program months) though some Veterans are seen for the duration of of intensive mindfulness meditation training that improves their parole placement depression, anxiety, and chronic pain while reducing suicidal ideation in Veterans. »» The VA-based Clinical Forensic Team currently consists of a VA outreach psychologist, psychiatrist, and social worker. • Home Based Primary. Patients who are home-bound have a primary care team that comes to the home to provide care. »» These providers act as the Veteran’s guide through system. Services include physicians, nursing, nutrition, pharmacy, oc- Services include: cupational therapy and psychology. 1. Weekly contact to monitor progress • TeleMental Health (TMH). The VA is expanding mental health 2. Liaison with the community housing partners services to rural veterans by providing mental health services at Community-Based Outpatient Clinics via telecomm. Veter- 3. Transitional focus that is meaning-based to assist in ans talk via telecomm video to their providers to receive ser- reducing alienation in community vices that they otherwise would have to travel great distances 4. Liaison with additional VA mental health/health to receive. Various locations within GLA have psychology, providers to facilitate integrated care psychiatry and dementia care. Additionally, GLA is working to 5. Interactions with parole/probation to fulfill super- expand the availability of TMH into the home so that veterans visory mandates with legitimate barriers to accessing MH care at a local facility (mobility barriers, great travel distance/time, etc.) can receive 6. GLA Mental Health providers from LAACC & WLA that treatment via computer/tablet from their homes. collaborated on a pilot study from a dance movement program that showed reductions in stress lev- • Primary Care-Mental Health Integration @ LAACC offers a els following the dance/movement intervention in number of evidence based services veterans diagnosed with PTSD.It was published in Federal Practitioner:

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»» Steinberg-Oren, SL; Krasnova, MT; Krasnov, I; Baker, MR; • By maintaining one of the largest dental education programs Ames, D. (July, 2016).Let’s Dance: A Holistic Approach to in DVA with 4 GLA sponsored Commission on Dental Ac- Treating Veterans with Posttraumatic Stress Disorder. Fed- creditation accredited residency programs, 2 major affiliations eral Practitioner, Vol. 33, No.7, pp. 44-49. with prestigious dental schools (UCLA and USC), and affilia- • Sepulveda Ambulatory Care Center offers Introduction to tions with several colleges of allied health, the GLA dental staff Relaxation and Meditation Groups and Continuing Practice keeps abreast of current practices and advances in dentistry Groups, which: which definitely benefits the Veterans and their dental care. »» Improve Veterans’ access to health and healing practice • GLA Dental Service has the only Dental Research Fellowship Program in DVA and its prolific clinical research program »» Increase Patient Centered Care, Access, Efficiency, Quality, is cutting-edge by demonstrating the relationship of certain Patient Empowerment through Less stigmatizing, Trans- medical conditions that are impacted by treating dental ad- diagnostic Care junct conditions. »» Help Veterans feel empowered to practice these life-long Social Work no-cost skills on their own in daily life • After participating in a 4-week group patients report • Participating in a pilot project through the Wounded Warrior improvements in: Care Network, a military and Veterans charity service organi- zation empowering injured Veterans and their families, to help »» Depression improve access to care and coordination of services for Vet- »» Anxiety erans across the nation. We are one of 4 VA Medical Centers who are participating in this project to partner with academic »» Suicidal ideation medical centers to help post-9/11 Veterans and their families »» Perceived stress to have access to needed care. VA GLAHS Social Work Ser- »» Need for pain meds vice is partnering with University of California, Los Angeles (UCLA) Operation Mend Program. As part of the Wounded » » Sleep trouble Warrior Care Network, the participating academic medical • Those who were more severely depressed or anxious centers offer specialized clinical services to include 2-3 weeks experienced more improvement of intensive outpatient program through multidisciplinary • Those who participated in follow-up groups experi- evaluation and individualized care. This collaboration will enced more improvement allow Veterans to be seamlessly referred to the VA following clinical treatment, and facilitate better sharing of information • Dental Service relative to Veterans and their medical needs. • GLA Dental Service excels in quality and safe Veteran- • Ms. Kathya Merchan, VA GLAHS Social Worker, is the VA centered Care Liaison for the Wounded Warrior Project. Ms. Merchan is at »» The highest standards of infection control and sterilization UCLA Operation Mend Program every Thursdays to meet in accordance with the stringent Reusable Medical Equip- with Veterans participating in the project, and is also part of ment (RME) guidelines are accomplished to provide safe the orientation team. Since June 2016, Ms. Merchan has as- and quality dental care to all veteran patients. sisted approximately 150 Veterans who were receiving care at UCLA Operation Mend in connecting and reintegrating them »» All dental unit waterlines are routinely tested for the deliv- to a VA Medical Center of their choice throughout the nation. ery of safe patient care. This included, but not limited to: »» To ensure the safe fabrication of quality dental applianc- »» Assisting Veterans get registered at VA of their choice es for all patients, the dental laboratories utilized assure that:1) they do not use lead, 2) they only use American »» Coordinating care between herself and Transition Care products, and 3) they do not outsource overseas. Management Coordinators at various VAs across the nation to ensure medical and mental health appointments are »» GLA Dental Service provides dental care to the largest scheduled catchment of homeless veterans in the VA system improving their quality of life as part of their road to recovery back »» Connecting Veterans to VA Regional Office for VA benefits into society. that they may be eligible for and Housing resources.

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Quality Management 5. Vacancies: The medical center reported having an authorized FTEE ceiling of 5,400 positions, which 460 positions • On the Road (OTR) Best Practice Tools sent out to all Clini- are vacant.H.R. has an authorized FTEE ceiling of 95 posi- cal Staff for reminders and ensuring corrective protocol and tions, which 28 positions are vacant. polices are followed. Recommendation: VISN 22 is working with all VA Health Care Conclusion: The VAGLAHS is facing significant challenges in facilities to address their staffing needs.Due to the number of staffing and recruitment.Since 2015, the VAGLAHS has had 7 vacancies at the VAGLAHS, The American Legion recommend acting Directors, which has had an impact on the medical cen- this be elevated to VA Central Office for immediate action. ter’s ability to move forward.At the time of SWS site visit, the medical center did not have an approved succession plan. When 6. Insufficient Funding for the Student Loan Repayment Pro- the SWS team toured the medical center, they did not see any in- gram. formation about Women Veterans, Patient Advocacy, or Military Recommendation: The American Legion will scheduling a meet- Sexual Trauma (MST) contact information. ing with VA Central Office to discuss what options are available Challenges to assist medical centers. 1. The Chief and Assistant Chief of Human Resources positions are vacant.In addition to the two top leadership vacancies in HR, there are 26 additional vacancies in HR.With the number of vacancies in HR, this poses serious challenges for the VAGLAHS that has over 400 vacancies. Recommendations: a. The VAGLAHS Executive Leadership team should continue to explore all options to address their vacancy pool. The executive leadership tasked staff to develop a strategic plan to address this challenge. b. The American Legion will draft a resolution calling for all VA employee positions to be classified as patient safety and exempt from current and future hiring freezes. 2. Executive Leadership lacks the authority to move funds to budget categories (accounts) where funding is needed. Recommendation: Since VA is restricted from transferring funds between accounts, this would require legislative changes.The American Legion will explore drafting a legislative resolution calling for Congress to provide VA the authority to transfer funding when appropriate. 3. Staff Recruitment and Retention: Lack of incentives to at- tract and retain good employees. Recommendation: The American Legion will scheduling a meeting with VA Central Office to discuss what options are available to assist medical centers. 4. Salaries are not competitive with salaries paid in the private sector for the same type of work. Recommendation: The American Legion will scheduling a meeting with VA Central Office to discuss what options are available to assist medical centers.

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